SASLHA COMMUNITY SERVICEMEMBERSHIP: 1 April 2012 – 31 March 2013
No Membership fees are payable for COMMUNITY SERVICE members
Please ensure that your MEMBERSHIP FORM was received by contacting SASLHA at 0861 113297or .
Please DO NOT FAX your forms/proof of payments, but send via post or e-mail.
Compulsory fields are marked *. Without these details your entry cannot be processed.
Non-compulsory fields will be entered should they be filled in
Please duplicate this page for additional rooms/ practices to be listed
GENERAL DETAILS
* THERAPIST’S NAME / ** THERAPIST’S SURNAME
(Please include Mr./Mrs./Miss/Ms/Dr/Prof/Other) / *
* IDENTITY NUMBER / *
* SASLHA MEMBERSHIP NUMBER
(if this is a new application just write NEW) / *
*NAME OF PRACTICE/ SCHOOL/ HOSPITAL
WHERE PLACED: / *
* PHYSICAL ADDRESS OF PRACTICE / SCHOOL/ HOSPITAL WHERE EMPLOYED: / *
*
* SUBURB: / *
* TOWN: / *
* POSTAL CODE: / *
* PROVINCE: / *
* TELEPHONE: / *
FAX:
* LANGUAGES IN WHICH SERVICES CAN BE PROVIDED: / *
* PREFERRED CLIENTELE (tick appropriate box) / ADULTS / CHILDREN / BOTH
POSTAL ADDRESS
(where you would like SASLHA correspondence to be sent):
POSTAL CODE: POSTAL ADDRESS: / *
MOBILE PHONE:
EMAIL ADDRESS
(where you would like SASLHA correspondence to be sent):
Please tick if you DO NOT wish your Email address and mobile phone number to be published in the membership directory (other details will be published)
Please tick if you DO NOT wish to be published in the membership directory at all (no longer practicing).
REGISTRATION DETAILS / TICK / TICK / TICK
* REGISTERED AS / AUDIOMETRICIAN (AM) / SPEECH THERAPIST AND AUDIOLOGIST (STA)
OTHER (Associate Membership – please specify): / AUDIOLOGIST (AU) / HEARING AID ACOUSTICIAN
(GAK)
SPEECH THERAPIST
(ST) / SPEECH CORRECTIONIST
(SGK)
* HPCSA REGISTRATION NUMBER / *
PLEASE COMPLETE BOTH SIDES OF THIS FORM!
AREAS OF SPECIAL INTEREST
PLEASE TICK NO MORE THAN FIVE, OTHERWISE GENERAL PRACTICE CODE (GEN) APPLIES
PLEASE NOTE: SOME CATEGORIES REQUIRE SPECIFIC QUALIFICATION OR TRAINING IN THE AREA
SPEECH-LANGUAGE THERAPISTS / AUDIOLOGISTSCODE
/ DESCRIPTION / TICK /CODE
/ DESCRIPTION / TICKAAC
/ Alternative and Augmentative Communication /ABR
/ Auditory Brainstem ResponseAPH / Aphasia / BAL / Balance disorders and vertigo
APR / Apraxia / CAPD / Central Auditory Processing Disorders
- specialist audiological testing
CLEF / Cleft lip and palate / CI / Cochlear Implant MAPing
- specific MAPing clinic
CP / Cerebral Palsy / ECOG / Electrocochleography
DARTH / Dysarthria / EML / Ear Mould Laboratory
DPHAG / Dysphagia / ENG / Electronystagmography
EI / Early Intervention / HA / Dispensing of Hearing Aids and Assistive Listening devices
FEED / Feeding / IND / Industrial Audiology
GEN / General speech therapy practice includes language, articulation and phonology / ML / Medico-Legal
LARY / Laryngectomy / NEO / Neonatal Screening
LAP / Linguistically-based auditory processing / NOISE / Noise Protection
ML / Medico-Legal / OAE / Otoacoustic Emissions
NDT / Neuro-developmental Therapy / REHAB / Auditory Rehabilitation
PDD / Pervasive Developmental Disorders / SSEP / Steady State Evoked Potentials
SLTHI / Speech-language therapy for hearing impairment / TIN / Tinnitus Retraining Therapy
STUT / Stuttering
TRACH / Tracheostomy
VOC / Voice Therapy
Who are you insured with for your professional indemnity?
Do you belong to any other speech or audio professional body? (if yes please indicate name of professional body) / Yes / No
SASLHA MEMBERSHIP DETAILS
REGISTRATION FEES- Community Service therapists do not pay registration fees.
*TYPE OF MEMBERSHIP (tick one) / R0.00
COMMUNITY SERVICE therapists do not pay membership fees
MYRTLE L ARON BURSARY FUND (Voluntary contribution) / R
*TOTAL DUE / R
NB: Student and Full members are to complete a separate form
ELECTRONIC OR DIRECT DEPOSITS
BANK: FIRST NATIONALBRANCH:CENTURIONBRANCH CODE:261550
A/C NAME: SASLHAA/C NUMBER: 5054 0051 766SWIFT ADDRESS: FIRNZAJJ
PLEASE USE YOUR SASLHA MEMBERSHIP NUMBER (OR NAME AND SURNAME) AS A REFERENCE FOR ALL ELECTRONIC AND DIRECT PAYMENTS